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A woman knocks on the door of an RV parked outside a firehouse in Lake Dreamland. It’s pouring rain, and inside the RV, Donald Davis sighs and tells his colleague to let the woman in.

It’s after 2 p.m. — closing time — and the woman is late. Davis hands her a small bag with three kinds of needles, alcohol wipes and antibiotic cream, and she goes on her way.

The RV is the site of the Lake Dreamland syringe exchange. And for three hours on this day, Davis, a harm reduction supervisor with the Volunteers of America Mid-States, has handed out these same bags to 43 people. Each person will use the needles to inject drugs — but hopefully won’t be sharing needles with anyone else.

Lisa Gillespie

The Lake Dreamland needle exchange.

“It’s about the spread of disease,” Davis said. “With Kentucky having one of the highest rates of hepatitis C in the country, you want to bring those numbers down and don’t want those numbers to increase.”

Kentucky will soon have the largest number of syringe exchange sites in the country, after nine more open in coming months.

At that point, Kentucky’s total sites will jump to 52, leaping ahead of California’s 42 sites and New Mexico’s 49 sites, which had in recent years topped the list of states with the most syringe exchanges. This is remarkable considering Kentucky’s size and population: geographically three times smaller than New Mexico and with about one-ninth the population of California.

Kentucky also only legalized syringe exchanges three years ago. State Public Health Epidemiologist Jonathan Ballard said the number of exchanges demonstrates a great need.

“They’re mostly in areas where it was most vulnerable,” Ballard said. “That’s public health.”

Syringe exchanges — or needle exchanges as they are often called — are open to anyone who uses a syringe or needle to inject drugs. These users can bring in their used syringes and exchange them for new ones. The exchanges also hand out safety boxes for syringe storage.

The goal is to prevent people from sharing needles, which can lead to outbreaks of diseases like hepatitis C and HIV.

Kentucky ranks in the top five states with the highest number of drug overdoses, in addition to its ranking as having some of the highest rates of hepatitis C. And while HIV/AIDS cases are declining the U.S., at the most recent count in 2015 Kentucky was holding steady with new cases.

Still Much To Be Done

Even though Kentucky will soon lead the country in the number of syringe exchanges, officials say there still aren’t enough in the state. One hurdle is the process local public health departments have to go through to set up these exchanges: they need approval from the city and county.

“There are still 27 vulnerable counties without approval,” Kentucky epidemiologist Jonathan Ballard said. That’s half of the 54 counties that the CDC analyzed as most at-risk.

Kathy Neal is the director of the Powell County Health Department, which set up a syringe exchange a little over a year ago. The county ranks 15th nationwide on the CDC list of counties vulnerable to an HIV outbreak. Even so, Neal said when they created the exchange there was a lot of pushback from the community.

“’We don’t want that here, it’s just going to bring these people in here’. These people,” she said. “They probably sit next to you at church and shop at Kroger with you.”

Georgia Heise is director of Three Rivers Health District — which includes Pendleton County. That was the first rural syringe exchange site in Kentucky. Heise said the community was mostly supportive when it opened in 2015.

“I think the reason they were fearless was because they had experienced a lot of loss related to overdoses, and wanted to combat it,” Heise said.

Heise said Pendleton County paved the way for other rural counties to do the same. But there’s still a lot of progress to be made in neighboring northern Kentucky counties. The area has some of the highest rates of hepatitis C and drug overdoses in the state, but out of eight counties, only Grant and Pendleton have syringe exchanges.

Even in Louisville, which now has five syringe exchange sites, there’s been some conflict about where to put the exchanges, according to Donald Davis with the Louisville Metro Health Department.

“We had to let them know that the people already live here,” Davis said. “They’re not going to move out to Lake Dreamland because the exchange is here.”

But there are no syringe exchanges in the counties surrounding Louisville, so Davis said people do drive up from Elizabethtown, Shepherdsville and Bardstown to turn in old syringes and get new ones.

Not Up To Standard

Studies show that syringe exchanges reduce the rate of HIV and other IV drug-related diseases. But there are many ways to operate a syringe exchanges. Research shows the best way to reduce disease risk is to allow a person to get new needles every time they visit, whether or not they’re turning in used ones.

But many counties favor requiring used needles to receive new ones, a so-called “one-for-one” model.

Kentucky’s guidance for exchanges allows one-for-one exchanges, but says there are serious limitations. One drawback is that people who use drugs may have legitimate reasons for not returning their used syringes, like if the syringe was confiscated by law enforcement or stolen by family members, for example.

“The needles themselves are .19 cents a piece, so it’s not like those are a cost. And it’s nothing compared to the cost of treating hepatitis C or HIV, for sure,” Heise said. “It’s been a real sticking point for a lot of people.”

Heise said city councils and county judges are most often in favor of the one-for-one model. Gov. Matt Bevin in 2016 also said he favors a one-for-one model.

Is It Working?

It’s still too early to gauge whether Kentucky’s syringe exchanges are reducing HIV and hepatitis C rates. Heise with Three Rivers District Health Department said around 60 percent of Kentuckians have never been tested for HIV. The syringe exchanges offer HIV and hepatitis C testing, so data showing an increase in rates of disease may be from the uptick in the number of people being tested.

“Some of these numbers may be due to the fact that we’re testing more, which is a good thing,” said Heise’s colleague, Allison Napier. “I think over time I’ll see a decrease.”

Neal with the Powell County Health Department said although she can’t yet tell if rates are going down, she thinks they will eventually. She said the fact that IV drug users are coming to the exchanges is a win.

“The first lady that we had, she said, ‘I’m hep C positive, but my boyfriend and I share needles and he’s not.’ And I said, ‘you know that’s not going to last long, right?’ She said, ‘Yeah, I know. That’s why I’m here. And he’s here, too. That way if he gets his and I get mine…’ At least you’re trying to do something about it,” Neal said.